Dental Benefits

Diagnostic and Preventive Services
• Oral exams (all types), twice per benefit period.

• Bitewing x-ray, one set per benefit period; Periapical x-ray, up to 4
x-rays per benefit period.

• Full-mouth x-rays once in any 60 consecutive months.

• Cleanings (all types), twice per benefit period.

• Fluoride, once per benefit period for dependents under age 14.

• Emergency palliative treatment.

• Sealants for dependent children under 16, once per tooth per
lifetime, limited to non-decayed 1st and 2nd permanent molars.

• Space maintainers, once in 5 years, to age 16.

100 %

90%

Basic Services
• Restorative services using synthetic porcelain and plastic
material (white) on front teeth and amalgam.

• Simple extractions

80%

70%

Major Services
• Surgical Extractions and other Oral Surgery Periodontics:
treatment for diseases of gums and bone supporting the teeth.

• Endodontics: root canal filling and pulpal therapy.

• Prosthetics: bridges and dentures; a replacement will be covered
only once in 5 years, but not during the first 12 months of Major
Services coverage.

• Crowns, jackets, labial veneers, inlays and onlays when required
for restorative purposes, once in 5 years.

Not
Covered

Not
Covered

Orthodontic Services
• For eligible dependents to age 19 who begin treatment while
covered by this plan.

• Note: a 24 month waiting period applies

Not
Covered

Not
Covered

Deductible (Applies to Basic Services Only)

$50 per person

$50 per person

Policy Year Benefit Max

$1,000 per person

$1,000 per person

Separate Lifetime Orthodontic Maximum

Not Covered

Not Covered

MAXAdvantage - Claims paid for cleanings, exams, x-rays,
fluoride treatments do not apply to benefit maximum.

Not Covered

Not Covered

Individual

$26.00

$10.00

$16.00

Individual + 1

$45.00

$10.00

$35.00

Family

$84.00

$10.00

$74.00

Diagnostic and Preventive Services
• Oral exams (all types), twice per benefit period.

• Bitewing x-ray, one set per benefit period; Periapical x-ray, up to 4
x-rays per benefit period.

• Full-mouth x-rays once in any 60 consecutive months.

• Cleanings (all types), twice per benefit period.

• Fluoride, once per benefit period for dependents under age 14.

• Emergency palliative treatment.

• Sealants for dependent children under 16, once per tooth per
lifetime, limited to non-decayed 1st and 2nd permanent molars.

• Space maintainers, once in 5 years, to age 16.

100%

100%

Basic Services
• Restorative services using synthetic porcelain and plastic
material (white) on front teeth and amalgam.

• Simple extractions

90%

80%

Major Services
• Surgical Extractions and other Oral Surgery Periodontics:
treatment for diseases of gums and bone supporting the teeth.

• Endodontics: root canal filling and pulpal therapy.

• Prosthetics: bridges and dentures; a replacement will be covered
only once in 5 years, but not during the first 12 months of Major
Services coverage.

• Crowns, jackets, labial veneers, inlays and onlays when required
for restorative purposes, once in 5 years.

60%

50%

Orthodontic Services
• For eligible dependents to age 19 who begin treatment while
covered by this plan.

• Note: a 24 month waiting period applies

50%

50%

Deductible (Applies to Basic Services Only)

$50 per person

$50 per person

Policy Year Benefit Max

$2,000 per person

$2,000 per person

Separate Lifetime Orthodontic Max

$1,500 per child to age 19

$1,500 per child to age 19

MAXAdvantage - Claims paid for cleanings, exams, x-rays,
fluoride treatments do not apply to benefit maximum.

Applies

Applies

Individual

$50.00

$10.00

$40.00

Individual + 1

$88.00

$10.00

$78.00

Family

$151.00

$10.00

$141.00